Improving hypertension management in my practice

Office blood pressure measurement

It is recommended that patients be sitting with their backs supported and feet on the ground when having their BP measured.5 I used to measure BP with the patient sitting on my examining table, which is not ideal.

I recently bought a validated automated BP monitor (ABPM)—the BpTRU6—and there is a comfortable chair, with armrests, for patients. I decided to do this after receiving a BpTRU for 2 weeks as part of a resident research project. The “BP chair” is located beside the practice scale and stadiometer, so all vitals get done in one area. Directly in patients’ line of sight there is a note in large print reminding them that they should have a 5-minute rest before having their BP taken; sit with their feet flat on the floor and their back supported; have avoided smoking or drinking coffee in the past 30 minutes; remain quiet while BP is being taken; and have no need to go to the bathroom.

My staff take BP measurements during annual checkups and diabetes or hypertension management appointments. They often point out and reiterate the recommendations on the wall. The ABPM takes several readings at 2-minute intervals. The machine discards the first reading; it will show the average BP reading at the push of a button. My secretary records this average in the patient’s chart.

My scheduler has several colours for different appointment types (eg, annual checkups or diabetes management follow-up) so that my secretary knows what vitals to measure when the patient comes in. If I need additional BP measurements, I will ask my patient to drop in to get an ABPM reading from my secretary, even if I am unavailable or out of the office.

Home monitoring

Guidelines also recommend home BP monitoring, as this can be a more accurate predictor of long-term morbidity.7,8 The Canadian Hypertension Society has approved several different monitors (www.hypertension.ca/chep/public/appareilsBPva.html); I use the LifeSource UA-767 Plus. I own 2 home BP monitors, which I lend to patients for home BP readings. The machine stores the readings and can later display the average BP. If necessary, I recommend my patients purchase the device (it costs about $120 and is available or can be ordered from most pharmacies and large general stores) and ask them to bring the machine to my office at their next appointment for validation. Home BP measurements should be, on average, 135/85 mm Hg or lower. Many of my patients now self-monitor and bring their home BP readings for shared review.

Electronic medical records

An electronic medical record (EMR) is another tool I use in hypertension management. The EMR has several prerecorded links to websites, such as the DASH eating plan at www.nhlbi.nih.gov/health/public/heart/hbp/dash or the Heart and Stroke Foundation BP Action Plan at ww2.heartandstroke.ca/hs_bp2.asp. When my patients are in, I will sometimes ask for their permission to e-mail them these links. When I copy and paste the link into the e-mail, it is automatically noted in the clinical record. Without an EMR, the links can be sent at a later time if the patient provides an e-mail address and consent.

I also use electronic flow sheets for monitoring BP measurements. Blood pressure, weight, body mass index, and waist circumference are automatically duplicated in the flow sheet as they are entered; however, medication changes are entered manually. This allows me to monitor and to show my patients the effect of lifestyle and medication changes over time. I sometimes print a copy of the flow sheet for the patient.